Patricia Coleman

Objectives To identify a comprehensive set of indicators to enable Primary Care Trust (PCT) commissioners in England and other NHS decision-makers to monitor the performance of systems of emergency and urgent care for which they are responsible. Methods Using a combination of Delphi RAND methods in three successive rounds of consultation and nominal group review, we canvassed expert opinion on 70 potential indicators as good measures of system performance. The two Delphi panels consisted of senior clinicians and researchers, and urgent care leads and commissioners in PCTs and Strategic Health Authorities (SHAs). The indicators were formatted into a questionnaire according to whether they were outcome, process, structure, or equity-based measures. Participants scored each indicator on a Likert scale of 1–9 and had the opportunity to consider their scores informed by the group scores and feedback. The questionnaire was refined after each round. To ensure that the indicators rated most highly by the Delphi panels covered all dimensions of performance, the results of the Delphi were reviewed by a nominal group consisting of two researchers and three clinicians from the local health services research network (LHSR). Results Overall, the process yielded 16 candidate indicators. It also produced a core set of serious, emergency and urgent care-sensitive conditions (defined as conditions whose exacerbations should be managed by a well-performing system without admission to an inpatient bed), for use with the indicators. Conclusions System-wide measures to monitor performance across multiple services should encourage providers to work for patient benefit in an integrated way. They will also assist commissioners to monitor and improve emergency and urgent care for their local populations. The indicators are now being calculated using routinely available data, and tested for their responsiveness to capture change over time.

Objectives—To examine the influence of evidence-based guidance on health care decisions, a study of the use of seven different sources and types of evidence-based guidance was carried out in senior health professionals in England with responsibilities either for directing and purchasing health care based in the health authorities, or providing clinical care to patients in trust hospitals or in primary care.

Objectives—To estimate the potential of general practice, minor injury units, walk in centres and NHS Direct to reduce non-urgent demands on accident and emergency (A&E) departments taking into account the patient's reasons for attending A&E. Methods—A questionnaire survey and notes review of 267 adults presenting to the A&E department of a large teaching hospital in Sheffield, England, triaged to the two lowest priority treatment streams, was conducted over seven weeks. Using defined criteria, patients were classified by the suitability of the presenting health problem to be managed by alternative immediate care services or only by A&E, and also by the likelihood, in similar circumstances, of patients presenting to other services given their reasons for seeking A&E care. Results—Full data were obtained for 96% of participants (255 of 267). Using objective criteria, it is estimated that 55% (95% CI 50%, 62%) of the health problems presented by a non-urgent population attending A&E are suitable for treatment in either general practice, or a minor injury unit, or a walk in centre or by self care after advice from NHS Direct. However, in almost one quarter (24%) of low priority patients who self referred, A&E was not the first contact with the health services for the presenting health problem. The reason for attending A&E cited most frequently by the patients was a belief that radiography was necessary. The reason given least often was seeking advice from a nurse practitioner. Taking into account the objective suitability of the health problem to be treated elsewhere, and the reasons for attending A&E given by the patients, it is estimated that, with similar health problems, as few as 7% (95% CI 3%, 10%) of the non-urgent A&E population may be expected to present to providers other than A&E in the future. Conclusions—The increasing availability of alternative services offering first contact care for non-urgent health problems, is likely to have little impact on the demand for A&E services.